Why Successful Innovations Fail: The Primary Care Curriculum at the University of New Mexico School of Medicine

What were you doing in 1977? I was a new assistant professor of anatomy at the University of New Mexico School of Medicine. It was the only medical school in a poor and medically underserved State with 23 indigenous Native American tribes and tens of thousands of people living at or below the poverty level along its border with Mexico. The state legislature asked the medical school to address these issues.

A handful of teachers and students in the medical school had experienced working and learning informally in small groups. Students’ curiosity blossomed, and their hunger to participate more actively in their own education was a palpable generative force. A few medical teachers further explored, adapted, and wove small-group, problem-based learning together with community-based learning into an idea about how the medical school might respond to the state’s health manpower needs and also reinvigorate learners and learning at all levels of the medical school.

A successful planning grant from the W. K. Kellogg Foundation funded a separate curriculum track, the Primary Care Curriculum to function in parallel to the traditional curriculum of the medical school. Twenty of the 73 entering medical students would learn and study in this new track during the first two of their four years of medical education. They would learn to be physicians based on inquiry, collaboration, self-directed study, and reflection. In addition there would be early and sustained clinical and community experience and a problem-based pedagogy. The sciences basic to medicine, including human behavior and public health were fully integrated. There were no separate departmental or discipline-based courses, no formal lectures, no traditional multiple-choice examinations, and no grades. Instead of teachers delivering content, they became facilitators in small groups promoting inquiry, synthesis and application to selected real-life health problems. Towards the end of their first year of study, Primary Care Curriculum students would leave the medical school to live and work for 16 weeks in a rural New Mexico community where they would see patients, learn, and continue under the supervision of a carefully selected practicing primary care physician. They would return to the medical school for their second year of study experienced, hungry, and eager to learn more. The Primary Care Curriculum was radical in its time.

For the next 15 years, the Primary Care Curriculum was funded by the W. K. Kellogg Foundation, the Pew Charitable Trusts, the Robert Wood Johnson Foundation, the Rockefeller Foundation, the US Department of Education, and the National Board of Medical Examiners, among others. The World Health Organization made it their model for curriculum change from within traditional medical schools. Publications, training institutes and outside consulting became a regular feature of my education practice. There was a steady flow of national and international visitors to the medical school, and we learned to articulate and share our experiences. The Academic Health Sciences Center of the University became internationally known for the Primary Care Curriculum. Similar approaches spread to the Physicians’ Assistant program, the College of Occupational Therapy, and a post-graduate research course in nuclear genetics in the Cancer Center. Other medical schools experimented with similar parallel problem-based curriculum tracks including Harvard, the University of Pennsylvania, Rush Medical College, Wake Forest, among others. The four co-directors consulted internationally in medical education for decades.

Meanwhile, back home in the University, resentment grew among some traditional curriculum faculty members over the attention received by the experimental curriculum. They felt unrecognized for their teaching and contributions to traditional medical education. They were either too busy with clinical care and research obligations or were opposed to the new pedagogy. After all, some said, if they didn’t teach the students and didn’t share their expertise, how could they possibly learn science and become competent physicians?  

By the early 1990s, managed care was sweeping the country and the state budget was shrinking. National and state economics forced the medical school to generate more and more of its own support through patient care and research. Medical education couldn’t compete financially. There was a demand for evidence to prove that the Primary Care Curriculum was better and more cost effective than the traditional curriculum. The leadership of the Primary Care Curriculum, cohesive for 15 years, began to split. The challenge came in the form of an option to apply for a grant offered by the Robert Wood Johnson Foundation. It would require the school to have a single curriculum, “the best of both.” The arguments were, “don’t kill the goose that lays golden eggs” (makes the school famous) or take the money and do the next level experiment in medical education, i.e., shift the entire school to a single innovative curriculum, 70% Primary Care Curriculum and 30% traditional curriculum. Ultimately the money argument won, and the two curricula merged, however prevailing forces took it to 70% traditional and 30% Primary Care.

The innovators got tired, retired or sought other arenas of work within the school. New leadership arrived with different ideas and loyalties. It was a different time educationally, politically, and economically. It took five years to develop a successful succession plan but by then it wasn’t enough. 2019 would be the 40th anniversary of the Primary Care Curriculum, if it still existed, but it doesn’t.

Today, the School of Medicine is still ranked highly for its primary care programs. Problem-based learning has been replaced by team-based learning, a less time-intensive pedagogy. The field of medical education has moved on as well. Small-group, problem-based learning spawned more complex issues such as social accountability of health professionals and education that has embraced ethics, professionalism, and trust between medical supervisors and post-graduate trainees. Worldwide there is an increased demand for better access to health care and more health professionals. More medical schools are being created, but there are not enough qualified medical educators and financial support continues to decrease. The focus shifted to outcome-based medical education and the delineation and measurement of a long list of performance competencies. Technology continues to perfuse the health sector while the need for primary care, community health, and qualified teachers increases.

So what happened to the successful innovative Primary Care Curriculum? So what can we learn from this story of successful innovation and failure that is true and useful to you, in whatever field you serve, and to others seeking to influence the future of the health-care workforce?  Looking through the lens of human systems dynamics can provide an explanation and guide future innovations in medical education. The issues in New Mexico and the response of the medical school were complex. Unfortunately, at that time, we could only reason in a straight line of cause and effect. There was not a shared language we could use to talk about the complex system in which we were engaged. Complex adaptive systems were unknown to us. The lexicon we needed had not yet been developed. The rules of the game, the paradigm of the day were, and to a great extent still are, fixed and finite. Medical education was and still is dominated by physicians trained to cure disease and to fix problems. Medical education is generally understood as a series of problems to be solved and solutions to be measured and added together to make a whole.

The Primary Care Curriculum was seen as a “success.” On the other hand, if success is defined as the ability to remain relevant and adapt to changing conditions, it failed. It was a narrative judged as unsuccessful based on numbers, time, and money. The immeasurable qualities of inquiry-based learning couldn’t shift the traditional patterns of rationalism, cognitive psychology, and the scientific method.

It seems ironic that we called the Primary Care Curriculum an experiment in medical education in order to gain time for it to mature. We assumed it would need space, but we also assumed it would be complete at some point in the distant future. It did mature, but it was never finished. If we had understood complex, emergent systems, we would have realized it would never be complete. It would be in a state of perpetual self-organizing. Instead, it became fixed as one of two polar positions in the medical school. It lost its flexibility, adaptability, and its complexity. We were so anxious to defend and preserve it that it failed be adaptive. The culture then was positivistic and win-lose and we followed that model as well. What we thought was excellent wasn’t good enough to adapt to changing forces and expectations.

I now realize that it was a mistake to call it an experiment because it stuck us into a win-lose evidence-based situation. Top-down leadership at the medical school assumed that education and learning worked like the scientific method and curative disease-oriented medical practice; both predictable and controllable finite games. To the contrary, education and learning are complex. They don’t get cured or solved. If education programs are not flexible enough to remain relevant and useful as conditions change, they disappear.

So What can be learned that is relevant to you? What follows below are some lessons learned as seen and understood through the lens of Human Systems Dynamics, together with 40 years of experience with teaching, consulting and innovation in health professions education at more than 100 institutions worldwide.

  • Complex systems, such as medical education curriculum tracks, don’t add together. Nor, can they be broken down into their component parts and later reassembled into a whole. Merging two different medical curriculum tracks, their associated infrastructure, and personnel, requires a reorganized structure that emerges as different and greater than the sum of its parts. We failed to create that new structure.
  • Polarization of two ideas, without recognizing their interdependence, creates tensions that cannot be contained in the existing structure. Both the traditional and the new curricula saw adaptation as giving in, as a win-lose threat to their existence. When tensions are understood as interdependent pairs, difference can be generative and new patterns of adaptation emerge .
  • Patterns of behavior observed in complex systems, such as health care and medical education, emerge from individuals following simple rules that apply to everyone even if the rules are implicit and not acknowledged by the participants. For example, in small-group, problem-based learning simple rules might be everybody learns; seek what is true and useful; give and get value for value. It is useful to identify patterns and behaviors that are complex; to name the simple rules that give rise to those patterns and to make them visible and accessible to small modifications.
  • Patterns are not problems. Problems have solutions and answers that are known. Their boundaries are well defined and fixed. For example, there is one right answer to a multiple-choice question. Many health professionals see their role as fixing problems. The scientific method was created to define and fix an approach to solve problems in a replicable way. However, some problems can’t be solved or fixed. They are complex and exist as patterns that shift over time. They can, however, be managed and influenced. For example, chronic illness, violence, equity of access to health care, effective teamwork, ageing, etc. The complex human dynamics involved in a program like the Primary Care Curriculum are more about being able to perceive and understand the dynamics of interactions among participants and bring them all together into a whole greater than the sum of the parts.
  • Teaching and learning are about entering into the space generated between people in an interdependent relationship that holds them together in shared interest. Differences have the potential to create an energy of change across connections that help us to make meaning and take informed action.
  • Uncertainty is the source of learning. Inquiry at the edge of uncertainty promotes a deep ecology of learning. It is an invitation to question explore curiosity such that we:
    • Turn judgment into curiosity
    • Turn conflict into shared exploration
    • Turn defensiveness into self-reflection
    • Turn assumptions into question
  • Things change when the tension of differences no longer fits the structure that holds conflicting parts together. To be effective as an agent for change in a workplace requires us to learn to recognize complex patterns and take informed action.

How can you take informed action in the face of uncertainty? Writing this Blog is an example of dealing with uncertainty. It was done by asking myself iterative cycles of three deceptively simple questions that constitute a process named Adaptive Action:

  1. What? What did I or do I observe? What happened? What is the data? What do I know?
  2. So What? So what does it mean for me? For you? For others? For the group reading this Blog? For the Human Systems Dynamics Institute? For the people of New Mexico? For the field of medical education? (the whole = group, School of Medicine; part = you and others involved; the greater whole = the people of the New Mexico and beyond).
  3. Now What? Now what can I do next? I invite you to register and learn more about working with your own complex adaptive systems in a terrifically interesting and useful online course, “Essential Skills in Action.” I invite you to explore the Human Systems Dynamics Institute website. Now what will you do next?

Now What? Let’s learn together. Join Mary Nations and me to talk the talk and walk the walk of patterns in the context of health professions education. ESME II: Essential Skills in Action is a collaboration between the Human Systems Dynamics Institute and the International Association of Medical Education in Europe. This is your invitation to take informed action to ease the stressful burden of trying to control and solve complex conflicts and issues in your everyday workplace. The context is yours, the patterns are shared. It works.

Register now to join us on April 2.

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